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World Asthma Day marks an opportunity to share the work we are doing to improve the quality of care we give patients while at the same time reducing our prescribing carbon footprint.
The National Review of Asthma Deaths in 2014 described why the UK has some of the poorest asthma outcomes in Europe: key findings included overuse of reliever salbutamol inhalers, and underuse of preventer steroid inhalers. At least two thirds of asthma deaths are thought to be preventable, and we have on average three deaths from asthma per day in the UK.
Inhaler emissions account for approximately 3% of the NHS carbon footprint (13% within primary care). The propellant used in metered dose inhalers (MDIs) is responsible for most of these emissions, and yet alternative options, with a significantly lower carbon footprint, such as dry powder inhalers (DPIs) and soft mist inhalers (SMI), are available and are clinically equivalent for many patients.
Whilst a small proportion of patients need these propellant-based MDIs (we recommend that children under 12 years of age, and those with certain clinical characteristics such as severe disease, use MDIs), most patients can inhale the same medication using a dry powder inhaler by using a short and sharp breath to take in the medicine. There are some additional advantages of these inhalers for this group of patients: they don’t require a spacer device, which are bulky to carry, and they have a dose counter which shows patients when their inhaler needs to be replaced and helps remind them if they have taken a dose.
Real-world studies have shown that for the right group of patients, these inhalers are equally effective, or even clinically advantageous. Other European countries use as few as 13% MDIs, compared to around 70% in the UK. A recent study from Asthma+Lung UK (ALUK) suggests most patients believe the environmental impact of inhalers should be a consideration in treatment choices.
Through the Pharmacy Quality scheme and general practice Investment and Impact Fund (IIF) we have an opportunity to improve the care of patients with asthma while reducing the carbon footprint. The IIF has four new indicators, which incentivise primary care networks to lower the number of asthma patients on six or more reliever inhalers per year and improve the uptake of corticosteroid inhalers, increasing asthma control, whilst also prescribing inhalers with a lower carbon footprint.
Patients have also been actively encouraged to return used and expired inhalers to community pharmacies for greener disposal. We are working closely with a variety of professional organisations representing GPs, practice nurses and pharmacists, to help spread the messages about good, green, asthma care and disposal of inhalers.
Patients should be supported to use the inhaler that is right for them. We know that the ‘greenest’ inhaler is the one that the patient will use and keeps their asthma well controlled.
It may seem like an enormous task to change our clinical practice with a condition as common as asthma. However, this is an excellent opportunity for quality improvement, and there are several ways to risk-stratify patients, for example by the number of reliever inhalers, or recent exacerbations requiring oral steroids or hospital admissions. Two fantastic resources written by colleagues at Greener Practice, a network encouraging action on sustainability in primary care, can help to implement this work.
The Greener Practice guide to inhaler prescribing explains how this work can be done, and gives information on the carbon footprint of the most common inhalers. The Asthma quality improvement toolkit gives ready-made quality improvement projects and patient searches which make it easier to get the ball rolling on this work. The recently published National bundle of care for children and young people with asthma sets out the blueprint for evidence-based interventions to help control and reduce the risk of asthma attacks in children and young people and prevent avoidable harm.
We are seeing amazing examples of improvement work happening on local and regional levels to implement these changes. Formularies and guidelines are being changed all around the country. In Kidderminster, a collaboration between primary and secondary care to develop a joint guideline, along with multi-disciplinary education of staff has seen significant reductions in MDI prescribing and patients are reporting they are able to better control their asthma on their new medication regimes.
In Halifax, West Yorkshire, a simple sign handwritten on a whiteboard in a community pharmacy has sparked conversations encouraging patients to return their inhalers to the pharmacy rather than putting their inhalers in household waste. Green disposal will further reduce the environmental impact of inhalers.
So, on World Asthma Day, I am optimistic. This work can help improve the quality of life and mortality rate from asthma, whilst reducing the environmental impact of our prescribing. The climate crisis is a health crisis, and anything we can do to reduce the NHS’s carbon emissions (5.4% of the UK total) will improve the health of the populations we serve both now and in future generations.
More resources on sustainable respiratory care are available on the Greener NHS FutureNHS page (you will need to register for a FutureNHS account to view the page).